This count of people and dollars significantly understates the benefits long-term care coverage would bring. Families of the severely disabled would receive badly needed help in caring for their impaired loved ones. Employed caregivers, or caregivers who could be employed, would be better able to balance responsibilities at home and on the job. Employers would reap the benefits of a more secure and productive work force.

Finally, and perhaps most important, all Americans would benefit from the security of knowing that if the need for long-term care should arise-for themselves, their parents, or their children-they would not be left to cope on their own. The nation would have a system to which everyone in need could turn for help.

REVENUES TO FINANCE COMMISSION RECOMMENDATIONS

The estimated new federal cost of the Commission's recommendations-health care plus long-term care for people of all ages-would be about $69.6 billion if fully implemented in 1990. Although some of these funds could be raised from reductions elsewhere in the federal budget, the Commission recognizes that new revenues will be necessary. To finance the new costs of the program entirely through new taxes in 1990 would require about $430, on average, from each nonpoor American adult. Various tax packages would spread the burden in different ways.

The Commission recommends that three criteria guide the selection of options for raising these revenues:

• Taxes should be progressive, requiring a higher contribution from those most able to bear increased tax burdens.

• Revenues should be able to grow fast enough to keep up with benefit growth.

• Contributions should come from people of all ages. A CALL FOR ACTION

Congress called upon the Commission to recommend legislation to ensure all Americans coverage for health and long-term care. With this report, the Commission fulfills its task. Now the Commission calls for action from the Congress and the President to turn its recommendations into law.

The Commission's investigations leave no doubt that Americans' fears about their health care system are well founded. Without action, people cannot rely on coverage they can afford or care when they need it.

The Commission not only documents the problems our citizens face; it puts forward workable solutions. In health care, we can build upon and strengthen the coverage we now have. In long-term care, we can identify priorities and build the coverage we now lack. We can build carefully and deliberately, one step leading to the next.

Universal coverage in an effective, efficient system is within our reach. We must act now.

Growth in the numbers of people likely to need long-term care makes improvements in the nation's financing of this care imperative for the well-being of all Americans. If disability rates remain what they are today, the number of elderly persons needing help with basic tasks is expected to double between 1990 and 2030-increasing from about 7 million to almost 14 million. The number of elderly requiring nursing home care will more than triple-rising from about 1.5 million to over 5 million (see Figure 5). And the use of high-technology and new medical breakthroughs may continue to extend the lives of disabled people of all ages.

It is highly unlikely that service availability will keep up with these growing needs. Demographic trends predict that fewer family members will be available to care for their disabled relatives. The private marketplace seems unable to develop an adequate home care delivery system even for those who can pay. The two major public programs-Medicare and Medicaid-have structural limitations that prevent them from meeting the projected need.

Without a change in public policy, more and more Americans will have difficulty getting the care they need in nursing homes as well as at home.

BLUEPRINT FOR LONG-TERM CARE REFORM

The Commission concludes that federal action is essential to change the nation's fundamentally flawed approach to long-term care financing, and that such action should follow an insurance strategy (public or private or both). The Commission rejects the alternative of encouraging private savings to cover long-term care costs. Depending on private savings concentrates the financial burden of severe impairment-an expensive and largely unpredictable eventon the unlucky few who experience it, rather than spreading it among the many who are at risk of impairment. Failure to reform the system on an insurance basis is not only to abandon today's elderly and disabled but also to condemn growing numbers of Americans to inadequate access to care in the future.

To prevent this outcome, the Commission unanimously adopted the following goal:

The Pepper Commission is committed to the development of recommendations for public policies that give Americans of all ages access to coverage that provides them necessary longterm care and adequate financial protection; that will assure quality care and choice of setting and will control costs; that will provide the financing required to assure access; and that will support research to prevent the need for long-term

care.

The Commission explored a range of possible strategies to achieve this objective. One strategy would be to enhance government protection for the low-income population and promote adequate private insurance protection for the better-off. The Commission believes, however, that to build such a two-tiered system would be to repeat the nation's unfortunate experience in health care. Too many people would continue to face impoverishment or find themselves dependent on a welfare-based system, a system unable to ensure access to quality care.

Another strategy would be to develop a comprehensive public insurance program for all long-term care services. The Commission believes that public or social insurance has considerable merit in guaranteeing adequate protection to all Americans, regardless of income. However, the Commission is concerned